by The daughter of a vulnerable woman who took her own life in prison after being left without clean underwear for 10 days and refusing phone calls to relatives has called for an urgent overhaul of England’s justice system.
A jury at Avon coroner’s court concluded last week that Eastwood Park prison in Gloucestershire failed to provide Kay Melhuish’s “basic human needs” and that neglect contributed to her death in July 2022 after “gross failures” in her care.
Melhuish waited 10 days to get clean underwear until a nurse intervened. After an initial phone call to her best friend, it took 16 days before she was allowed another call.
Melhuish was taken into custody during a mental health crisis and was being held on remand. Desperate for access to her children, she was caught putting a knife to her own throat outside where two of her children lived with her ex-partner.
The prison was aware of his history of suicide attempts and self-harm. It was also warned that her autism combined with PTSD complicated by childhood violence made it difficult for her to cope with the noise, the use of force and the loss of control in prison.
Despite 11 self-harm and suicide reviews being carried out in the 19 days Melhuish spent there, a mandatory care plan with supportive actions was never prepared.
On 4 July 2022, less than three weeks after Melhuish arrived at the prison, she was found unconscious in her cell, and died in hospital three days later, aged 36.
Officers saw her making clear preparations to end her life that day but did not consider placing her under constant supervision.
The family says Melhuish’s case is a stark reminder of the dangers of a justice system that criminalizes vulnerable women.
In an interview with the Guardian, her daughter Oceana, 20, a care worker from Exeter, said: “Mum was ill, she wasn’t bad. She had harmed herself and that was a pretty big red flag. She wasn’t a criminal, she was just someone who was very sick.”
A government review of sentencing is expected to look at ways to reduce the number of women in prison and look to end shorter sentences and treat more offenders in the community.
Deborah Coles, director of the charity Inquest, said: “If ever a death was going to spark radical change in the way women in conflict with the law are treated, this should be it. I call on the prisons minister to respond to the appalling circumstances surrounding Kay Melhuish’s case. We ask again why she was imprisoned in the first place.”
Eastwood Park was given the lowest safety grade in an inspection carried out in 2022, which warned of gaps in the care of the most vulnerable and disturbed women.
During her time at Eastwood Park, Melhuish was repeatedly seen clapping her hands over her ears trying to stop noise, running into walls, hitting herself and creating ways to end her life himself.
A neurodiversity specialist provided a communication support plan, which has since left and has not been replaced, but the court heard almost no one read it.
Oceana said: “The prison didn’t try hard enough. That’s why I lost my mum just before I turned 18 and now I’ll have to go through my whole life without my mum – all five of us will have children. Every professional who could do something, make a difference – literally, just give her a pair of pants or give her a phone – was not even looked at.”
Before Melhuish even stepped into Eastwood Park there were warnings. She had to be cut from a Serco van after making a credible suicide attempt, with a letter from her psychiatrist saying prison would put her life at risk.
Her best friend, Cathy Goldsmith, had called ahead from the court to inform the prison that it was a dangerous environment for her due to Melhuish’s neuroticism and mental health.
Melhuish arrived without any medication and when she was given the diazepam she was dependent on, the dose was dangerously reduced.
When she last called Goldsmith she was distressed, telling her friend that she “looked like Batman” after hitting herself and that her medication was wrong.
Goldsmith believes that if Melhuish had been given proper access to a phone, “she would still be here today”. The records show that Melhuish tried several times to call her from the jail phone but failed to add her number.
Goldsmith said of the prison: “They have blood on their hands. Professionals and I warned them. Kay should never have been in prison. Shut it down and build some therapy units for these poor women.”
Ceri Lloyd-Hughes, solicitor for the Melhuish family, said: “The tragedy of Kay’s death is that it could have been avoided. Two more vulnerable prisoners at Eastwood Park died by suicide within six months of Kay. Swift action must now be taken to address the coroner’s concerns that similar deaths will occur in the future at Eastwood Park or other prisons unless things change.”
The story of Melhuish’s final imprisonment is also one of the missed opportunities to intervene. Her family says that when she threatened to end her life two years earlier, the police used a stun gun against her and she was euthanized. They expected her to be treated for 28 days, but two days later she came home again, still very ill.
Oceana said: “My mum is not the first and she won’t be the last if nothing changes. And obviously change won’t bring Mom back, but if we can save lives in the future and save families from the grief we’ve gone through, that’s as good as it gets.”
A Ministry of Justice spokesman said: “Our thoughts remain with the family and friends of Kay Melhuish. The circumstances of her tragic death are why the new government is ending the designation of the prison as a ‘safe haven’ and will soon form a women’s justice board, tasked with reducing the number of women going to prison.
“HMP Eastwood Park has completed improvements and training so that women are better supported, particularly those in the early days of custody. More psychologists are also being recruited to help those with complex needs.”
